S02 ATTACHMENT D.32 - 116A-02_SOP_SCREENING_AND_MANAGEMENT_OF_THE_SUICIDAL-HOMOCIDAL_PATIENT.pdf

SCREENING AND MANAGEMENT OF THE SUICIDAL/HOMICIDAL PATIENT

SOP 116A-02

Veteran’s Health Care System of the Ozarks Fayetteville, AR 72703

Signatory Authority:

VHSO Chief of Mental Health

Responsible Owner:

Associate Chief of Staff, Mental Health

Service Line(s):

Mental Health

Effective Date:

September 28, 2020

Recertification Date:

September 28, 2020

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures on the evaluation and management of the suicidal or homicidal patient. This SOP must be followed by all personnel working at the main medical center facility as well as community-based outpatient clinics (CBOC) who interact with patients.

b. This SOP sets forth mandatory procedures and processes to ensure compliance with the VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide.

2. PROCEDURES

a. Suicide risk screening. All patients will be screened for suicide risk, utilizing measure(s) endorsed by latest clinical practice guidelines.

(1) PHQ2 + I9, PC PTSD. To be completed on every patient annually in Primary Care, Home-Based Primary Care, Homeless-Patient Aligned Care Teams, and PCMHI.

(2) I9.

(a) To be completed at referral or intake if >30 days from referral in following settings.

1. Sleep Clinic

2. Pain Clinic

(b) To be completed within 24 hours of admission and within 24 hours before discharge home in following settings.

1. Inpatient Med/Surg

2. Inpatient Rehabilitation

September 28, 2020 SOP 116A-02

3. Community Living Center

(3) C-SSRS

(a) To be completed immediately upon every positive I9 screening as well as in the following settings.

1. Emergency Department/Urgent Care

2. Outpatient MH

a. During intake evaluation

b. As clinically indicated

c. Annually at minimum

3. Inpatient MH

a. Within 24 hours of admission, and within 24 hours prior to discharge

4. MHRRTP

a. Within 24 hours of admission, and within 24 hours prior to discharge

(4) CSRE (Comprehensive Suicide Risk Evaluation).

(a) To be completed within 24 hours of hospital admission following any positive C- SSRS, and on same day of positive C-SSRS in ambulatory settings.

(b) Separate evaluations to be completed during first and last weeks of all MHRRTP admissions

(5) Reassessment of suicide risk.

(a) Suicide risk reassessment should be done on every change of level of care, with any acute clinical change, within 24 hours of discharge from hospital/RRTP, and as clinically indicated.

b. Management of acutely parasuicidal/suicidal/homicidal patient.

(1) All patients either screening positive for acute suicidal ideation or expressing thoughts of harm to self or others should be kept on 1:1 close observation until LIP can complete full assessment and provide further recommendations.

(2) If patient is located in an area other than the inpatient mental health ward, an environmental risk assessment must be conducted by nursing staff to identify and remove as possible any items which may be used for harm to self or others.

(3) The assessing LIP should determine the least restrictive environment for the patient based on clinical data including suicide risk screening tools, and follow through on actions including but not limited to: admission to inpatient mental health, referral to nearest emergency department, engagement with mental health service clinicians, engagement with Suicide Prevention Coordinator(s), engagement with patient family and friends. If necessary, it may be appropriate to place the patient on a 72-hour involuntary hold. Observation status for inpatient admissions should be determined based on clinical data including suicide risk screenings, and coordination with psychiatrist when appropriate. LIP should thoroughly document their assessment, suicide risk evaluation, and plan within 24 hours.

c. Suicide Behavior and Overdose Report (SBOR). When a clinician is informed from a patient regarding a suicide attempt or overdose, they must either ensure that an SBOR has been completed for that event, or complete one themselves.

(1) The following disciplines may complete an SBOR: MD/DO, PhD/PsyD, Clinical Pharmacy Specialist, LCSW/LMSW/LISW, LMFT, LPMHC, Addiction Therapist, RN, APRN, PA, Rehabilitation Counselor

d. One-to one (1:1) Observation. *Please see VHA Directive 1036 Standards for Observation in VA Medical Facilities, Appendix B for documentation requirements.

(1) 1:1 observation is defined as the constant observation of one patient by one staff.

Staff providing 1:1 observation should only be observing one patient at a time and have no other responsibilities during the assignment to 1:1 observation.

(2) Placing a patient on one-to-one observation requires a provider’s order with the following exception: any professional staff member will ensure that a Veteran who is in their clinical assessment at imminent risk for attempting suicide and/or homicide shall be placed on one-to-one observation until the patient can be evaluated by a provider.

(3) The patient must be in direct line of sight of the 1:1 observer at all times and be no more than an ‘Arm’s length’ away. The observer must not be distracted by reading or performing other duties. While under 1:1 observation, any restroom or shower visit requires an escort who can visually monitor the patient at no more than an ‘Arm’s length’ distance. Observation by cameras cannot substitute for 1:1 observation. Such restrictions on the Veteran’s freedom must be consistent with statutory and regulatory authority and be sensitive to privacy and dignity.

(4) Constant observation is documented as ‘maintained’ on each patient for that unit (area of care) for each shift or time required and is documented in the medical record.

Documentation includes the rationale for the observation, patient’s behavior, activity, safety, and unit location. The treatment plan is updated to reflect the observation.

(5) The nursing staff is responsible for providing activities of daily living (ADL) care/hydration/nutrition to the patient.

(6) The nursing staff will notify the registered nurse assigned to the patient of any changes in condition or behavior.

e. Every 15 Minute (q15 minute) Checks.

(1) Fifteen (15) minute safety checks can be initiated by a registered nurse or provider.

(2) The nursing staff assigned to monitoring patients on every 15-minute safety checks will observe the patient's behavior, welfare, safety, location, and immediate environment every 15 minutes through direct line of sight observation. The security camera or other telecommunication devices cannot be used to complete every 15-minute checks. At times, the patient should be checked sooner than 15 minutes to ensure that the patient does not "time" staff and harm themselves in-between safety checks.

(3) The nursing staff will notify the registered nurse assigned to the patient of any changes in condition or behavior.

(4) Documentation in the medical record from observation will include rationale for observation, patient’s behavior, activity, safety, and unit location. Q15 minutes is also included in treatment plan.

3. ASSIGNMENT OF RESPONSIBILITIES

a. Medical Center Director. Responsible for approval, support, establishment and continuance of a program to identify patients at risk for parasuicidal/suicidal/homicidal behavior, management of such patients and prevention of parasuicide/suicide/homicide.

The VHSO Director is also responsible for providing education/training for employees.

b. Service Chiefs and Supervisors. Responsible for implementation and employee education regarding this SOP.

c. Suicide Prevention Coordinator(s). Facilitates implementation of suicide prevention strategies at VHSO. Activities include: education of clinical and non-clinical staff on the signs and symptom of parasuicidal/suicidal/homicidal behavior in high risk and at risk patients, support for the identification of Veterans at high risk; coordinating enhanced care when needed; education of the Veterans, family members, caregivers and members of the community on risk factors and warning signs for suicide, as well as, treatment options and resources at the VA and in the community. The SPC chairs the committee for Category 1 Suicide Patient Record Flag review. *Please see VHA Directive 1071 Suicide Risk and Intervention Training of Employees, and VHA Directive 2008-036 Use of Patient Record Flags to Identify Patients at High Risk for Suicide.

d. Safety Officer. Responsible for conducting ongoing safety inspections throughout VHSO in order to ensure that safety aspects are addressed for Suicide Prevention.

e. Mental Health Environment of Care Team. Multidisciplinary team responsible for semiannual environment of care assessment covering ED and inpatient mental health unit. *Please see VHA Directive 1167 Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients.

f. VHSO Employees. All employees of VHSO are expected to adhere to the procedures outlined in this SOP. Employees are further required to review the content of this SOP annually through mandatory continuing education. Annual TMS training on suicide risk assessment and management to be completed by all clinical staff.

4. DEFINITIONS

a. Non-Suicidal Self-Directed Violence Ideation. Self-reported thoughts regarding a person’s desire to engage in self-inflicted potentially injurious behavior. There is no evidence of suicidal intent.

b. Suicidal Ideation. Thoughts of engaging in suicide-related behavior.

c. Preparatory. Acts or preparation towards engaging in Self-Directed Violence, but before potential for injury has begun. This can include anything beyond a verbalization or thought, such as assembling a method (e.g., buying a gun, collecting pills) or preparing for one’s death by suicide (e.g., writing a suicide note, giving things away).

d. Non-Suicidal Self-Directed Violence. Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is no evidence, whether implicit or explicit, of suicidal intent.

e. Undetermined Self-Directed Violence. Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. Suicidal intent is unclear based upon the available evidence.

f. Suicidal Self-Directed Violence. Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is evidence, whether implicit or explicit, of suicidal intent.

g. Self-Directed Violence. Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself.

h. Suicide Intent. There is past or present evidence (implicit or explicit) that an individual wishes to die, means to kill him/herself, and understands the probable consequences of his/her actions or potential actions. Suicidal intent can be determined retrospectively and in the absence of suicidal behavior.

i. Physical Injury. A (suspected) bodily lesion resulting from acute overexposure to energy (this can be mechanical, thermal, electrical, chemical, or radiant) interacting with the body in amounts or rates that exceed the threshold of physiological tolerance. In some cases, an injury results from an insufficiency of vital elements, such as oxygen.

Acute poisonings and toxic effects, including overdoses of substances and wrong substances given or taken in error are included, as are adverse effects and complications of therapeutic, surgical and medical care. Psychological injury is excluded in this context.

j. Interrupted by Self or Other. A person takes steps to injure self but is stopped by self/another person prior to fatal injury. The interruption may occur at any point.

k. Suicide Attempt. A non-fatal self-inflicted potentially injurious behavior with any intent to die as a result of the behavior.

l. Suicide. Death caused by self-inflicted injurious behavior with any intent to die as a result of the behavior.

m. One-to-one (1:1) Observation. The constant observation of one patient by one staff. (see procedures for more detail).

n. Every 15-minute (q15 minute) checks. Visual observation of a patient’s location and behavior by staff member at least every 15 minutes.

o. I9. Question 9 from PHQ-9 depression screening tool (“Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?”).

p. PHQ-2 + I9. Depression and suicide risk screening tool.

q. PC-PTSD + I9. PTSD and suicide risk screening tool.

5. REFERENCES

a. Self-Directed Violence Classification System. CDC, MIRECC. 2018.

https://www.mirecc.va.gov/visn19/docs/presentations/RM_MIRECC_SDVCS_11_26_18 .pdf.

b. 2020 National Patient Safety Goals, The Joint Commission. 2020.

https://www.jointcommission.org/standards/national-patient-safety-goals/.

c. VA/DoD Clinical Practice Guideline. Assessment and Management of Patients at Risk for Suicide, v2.0, 2019.

https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal50 88212019.pdf.

d. VHA Directive 1036 Standards for Observation in VA Medical Facilities, Appendix B. January 13, 2020.

e. VHA Directive 1071 Suicide Risk and Intervention Training of Employees.

December 22, 2017.

f. VHA Directive 2008-036 Use of Patient Record Flags to Identify Patients at High Risk for Suicide. July 18, 2008.

https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf

g. VHA Directive 1167 Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients. May 12, 2017.

6. REVIEW: This SOP must be reviewed at minimum at recertification and including when there are changes to the National Patient Safety Goals, the VA/DoD Clinical Practice Guidelines, or associated VHA directives. This review is documented on the VHSO Mental Health SharePoint site (see https://dvagov.sharepoint.com/sites/VHAfav/mhs/SitePages/Home.aspx). NOTE: This is an internal VA website that is not available to the public.

7. RECERTIFICATION: This SOP is scheduled for recertification on or before the last working day of May 2025. In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

Aaron Carson MD Associate Chief of Staff, Mental Health Date Approved: September 28, 2020

[NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: Emailed to the VHSO Mental Health Email Distribution List. SOP’s are available at: VHSO Intranet. NOTE: This is an internal VA website that is not available to the public.

https://dvagov.sharepoint.com/sites/VHAfav/mhs/SitePages/Home.aspx